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Resp & Qualifications
PURPOSE: The Vice President, Payment Integrity and Oversight ensures the successful operation and delivery of Payment Integrity services by securing a payment cycle that achieves accurate and timely transactions. The Vice President is also responsible for the detection, investigation, and mitigation of loss related to fraud, waste and abuse.
This role leads teams accountable for controlling fraud, waste & abuse (FWA), subrogation activities, including worker’s compensation, vendor recovery and Payment Integrity efforts. He/she sets strategy for the Company’s fraud fighting and anti-fraud efforts and coordinates with the Office of Corporate Counsel to ensure the Company s efforts to detect, prevent and investigate FWA by providers, members, employees or others meet all necessary regulatory requirements.
The role requires cross-functional work to ensure department and corporate strategies are executed and achieved enterprise-wide.
Under the general direction of the Executive Vice President & General Counsel the incumbent’s accountabilities include, but are not limited to:
Strategic Planning and Budget Management:
Fraud, Waste and Abuse:
Performs other duties as necessary or assigned.
• Bachelor s Degree in business administration (accounting, finance), management sciences, nursing, criminal justice, and/or related technology fields . In lieu of a Bachelor’s Degree, an additional 4 years of relevant experience is required.
• Minimum of ten years of experience in fraud and abuse investigations or health care fraud experience.
• At least one professional certification as a Certified Public Accountant (CPA), Certified Fraud Examiner (CFE), or Accredited Healthcare Fraud Investigator (AHFI).
• 5 years of experience leading and managing subrogation activities and claims recovery for an insurance company.
• 10 years of progressive management experience.
• Familiarity with applicable regulations governing healthcare fraud, waste and abuse.
• Extensive knowledge of Medicare and Medicaid health-care regulations, legislation and laws, auditing reports and system functions, with in-depth operational experience of medical billing, coding and provider claims processing and adjustment.
• Demonstrated leadership, coaching and mentoring skills for all levels of staff.
• Excellent written, verbal, analytical, organizational, and presentation skills.
• Excellent time management, prioritization, and delegation skills.
• Knowledge of investigatory best practices and methodologies and tools, including ability to manage investigation resources.
• Strong data analytical skills. Ability to assess complex problems and recommend appropriate solutions related to issues at all levels, internally and externally.
• Experience in evaluating claims using various forensic techniques and knowledge of related legal/regulatory issues.
• Demonstrated ability in developing and maintaining effective working relationships with a variety of federal, state, and local law enforcement agencies. Ability to communicate effectively, including but not limited to, annual SIU reporting to the federal government as required and Departments of Insurance.
• Proven effective communication, interpersonal, and motivational skills. Objective collaborative approach.
• Demonstrated ability to think strategically and to proactively manage the implementation of broad based and strategic initiatives. Demonstrated ability to anticipate future trends accurately.
• Demonstrated ability to develop innovative long-term strategies/plans based on industry analysis, local markets and organizational capabilities.
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple demands from internal and external stakeholders, within set expectations for service excellence.
• Must commit to frequent travel to multiple staff sites and CareFirst offices.
Master's degree or MBA from an accredited institution
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 10/06/2019
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship